Functional Assessment of the Older Adult

1. Functional Assessmentof the Older Adult Chapter 30

2. Functional Assessment of the Older Adult • Comprehensive assessment of an older adult • Requires knowledge of normal aging changes and effects of chronic diseases, heredity, and lifestyle • Comprehensive geriatric assessment is multidimensional and incorporates not only physical examination, but also assessments of: • Mental status • Functional status • Social and economic status • Pain • Examination of physical environment for safety concerns

3. Functional Assessment of the Older Adult(cont.) • Comprehensive assessment of an older adult (cont.) • Multiple disciplines may participate in assessment • Physicians, nurses, physical, occupational and speech therapists, social workers, case managers, nutritionists, and pharmacists • Early recognition of disabilities and treatable conditions is instrumental in preserving function and quality of life for older adults

4. Functional Assessment of the Older Adult(cont.) • U.S. has large and expanding population of older adults • In 2004 persons 65 years of age and older totaled 12% of U.S. population and 38% of acute hospital discharges and consumed 44% of total inpatient days of care • Older adults also comprise 80% of home care visits and 90% of those in nursing homes • Number of adults aged 65 years and older in U.S. with disabilities is approximately 7 million

5. Functional Assessment of the Older Adult(cont.) • Normal changes of aging do not necessarily represent pathology • With imposition of acute and chronic illnesses, including hospitalization, older adults may be predisposed to disability • Older adults may arrive not only with an acute illness such as pneumonia, but also with ongoing chronic “geriatric syndromes,” such as urinary incontinence, fragile skin, confusion, problems with eating or feeding, falls, and sleep disorders • If these syndromes are not identified early, an older adult may have functional decline

6. Functional Ability • Functional ability refers to one’s ability to perform activities necessary to live in modern society • Includes driving, using telephone, and performing personal tasks such as bathing and toileting • Also incorporates older adult’s physiologic and psychological status and physical and social environment • Functional status: individual’s actual performance of activities and tasks associated with his or her current life roles and dependent on motivation, vision and hearing, degree of assistance needed to accomplish tasks, and cognition

7. Functional Ability(cont.) • Functional ability refers to one’s ability to perform activities necessary to live in modern society (cont.) • Functional status is not static; older adults may move continuously through varying stages of independence and disability • Lack of social support or safe physical setting are environmental issues affecting functional status and ability to live independently • Interaction of these components provides a snapshot of an older adult’s functional status at a given point in time

8. Functional Ability(cont.) • Refers to one’s ability to perform activities necessary to live in modern society (cont.) • Assessment of function is important geriatric tenet to provide a baseline • For continuing comparison • Predict prognosis • Assists practitioner with objective measures to determine efficacy of treatments

9. Functional Ability(cont.) • Functional ability refers to one’s ability to perform activities necessary to live in modern society (cont.) • Functional assessment • Basis for care planning, goal setting, and discharge planning • Needed for eligibility to obtain services such as durable medical equipment, home modifications, and inpatient or outpatient rehabilitation services • For older adult and family, a functional assessment can identify areas for current and future planning

10. Functional Ability(cont.) • Functional assessment includes three overarching domains • Activities of daily living (ADL), • Instrumental activities of daily living (IADL) • Mobility

11. Functional Ability(cont.) • Two approaches to functional assessment • Individual’s self-report about his or her ability to perform tasks • Observing his or her ability to perform tasks • For persons with memory problems, use of surrogate reporters (proxy reports), such as family members or caregivers may be necessary, keeping in mind that they may either overestimate or underestimate actual abilities

12. Functional Ability(cont.) • Activities of daily living • ADLs measure tasks necessary for self-care • Eating • Bathing • Grooming (washing, combing hair, shaving, cleaning teeth, dressing) • Toileting • Walking, including propelling a wheelchair, using stairs • Transferring, such as bed to chair • ADL instruments are designed as either self-report, observation of tasks, or proxy/surrogate report

13. Functional Ability(cont.) • ADL instruments • Katz Index of Independence in ADL • Barthel Index • Functional Independence Measure (FIM) • Rapid Disability Rating Scale-2 (RDS-2)

14. Functional Ability(cont.) • Instrumental activities of daily living • Goal of measuring functional abilities necessary for independent community living • IADLs include shopping, meal preparation, housekeeping, laundry, managing finances, taking medications, and using transportation • These instruments may have cultural and gender biases, especially in older cohorts • IADL instruments measure tasks historically done by women, and most do not address activities done primarily by men, such as home repairs and working in yard

15. Functional Ability(cont.) • IADL instruments • Lawton Instrumental Activities of Daily Living • OARS-IADL , Older Americans Resources and Services Multidimensional Functional Assessment Questionnaire-IADL • Direct Assessment of Functional Abilities (DAFA)

16. Functional Ability(cont.) • Advanced activities of daily living (AADLs) • Activities older adults perform as family member, member of society and community, including occupational and recreational activities • Various AADL instruments commonly include self-care, mobility, work (either paid or volunteer), recreational activities/hobbies, and socialization • Occupational therapists often perform assessment of AADLs • Older adult sets priorities for these activities so that interventions can be individualized

17. Functional Ability(cont.) • AADL instruments • Physical Performance Test (PPT) • Performance Activities of Daily Living (PADL) • Up and Go Test

18. Functional Ability(cont.) • Assessment of cognition • Assessment of cognitive status in older adults is an important part of the functional assessment • Domains of cognition included in most mental status assessments • Attention • Memory • Orientation • Language • Visuospatial skills • Higher cognitive functions

19. Functional Ability(cont.) • Altered cognition in older adults is commonly attributed to three disorders • Dementia • Delirium • Depression

20. Functional Ability(cont.) • Social domain • Focuses on relationships within family, social groups, and community • Comprises multiple dimensions including sources of formal and informal assistance available from those relationships • Comprehensive social assessment is typically spread over several evaluation periods

21. Functional Ability(cont.) • Social domain (cont.) • Informal support • Includes family and close long-time friends, and is usually provided free of charge • Total economic value of informal caregiving in U.S. estimated to be more than twice amount paid for nursing home care • Services provided include tasks such as shopping, bathing, feeding, and paying bills

22. Functional Ability(cont.) • Social domain (cont.) • Formal supports • Include programs such as social welfare and other social service and health care delivery agencies such as home health care • Several studies conclude that presence of a caregiver is most important factor in discharge plan of older adults from an acute care hospital • Knowing who would be available to help person if he or she becomes ill is important to document even for healthy elders • Several standardized assessment instruments are available to provide structured assessment

23. Caregiver Assessment • Primary caregivers • Increased stress, burden, and impaired physical health for caregiver • Especially spouse and adult children often face • High levels of demand • Limitations on personal freedom

24. Caregiver Assessment(cont.) • Most elders with functional impairment live with help of informal support • Spouse, daughter, or other family member • High levels of functional dependency place a burden on caregiver and may result in caregiver: • Burnout • Sleep disturbances • Depression • Morbidity • Increased mortality

25. Caregiver Assessment(cont.) • Older person’s need for institutionalization often better predicted from assessment of caregiver than from severity of patient’s illness • Health and well-being of patient and caregiver are closely linked • Part of caring for a frail elder involves paying attention to the well-being of caregiver • Social worker may help identify programs such as caregiver support groups, respite programs, adult day care, or hired home health aides

26. Caregiver Assessment(cont.) • Assessment of caregiver burden • All caregivers should be screened for caregiver burden • Caregiver burden is perceived strain by person who cares for an elderly, chronically ill, or disabled person • Caregiver burden is linked to caregiver’s ability to cope and handle stress • Level of care older adult requires may exceed caregiver ability • Signs of possible caregiver burnout include multiple somatic complaints, increased stress and anxiety, social isolation, depression, and weight loss

27. Caregiver Assessment(cont.) • Assessment of caregiver burden (cont.) • Caregiver Strain Index • Screening tool that identifies caregivers needing a more comprehensive assessment • Brief tool with 13 questions addressing potential strain in employment, financial, physical, social, and time domains • Caregiver stress can lead to elder mistreatment • Thorough assessment may identify opportunities to prevent and stop elder mistreatment

28. Caregiver Assessment(cont.) • Elder mistreatment • Elder abuse and neglect refer to acts of omission or commission that result in harm or threatened harm to the health or welfare of an older adult • Elder abuse is umbrella term used to describe one or more of following situations: physical abuse, sexual abuse, emotional or psychologic abuse, financial or material exploitation, abandonment, neglect, or a combination of these • One study estimates that more than 551,000 people who are 60 years of age and over and who are living in community experience abuse, neglect, or self-neglect

29. Caregiver Assessment(cont.) • Elder mistreatment (cont.) • Among known perpetrators of abuse and neglect, a family member was identified in 90% of cases • Two thirds of perpetrators were spouses and adult children • Health care providers may assume behavior exhibited during assessment is due to a dementia, confusion, or paranoia, therefore minimizing elder’s report of mistreatment • Health professionals and general public lack awareness on how pervasive elder mistreatment is

30. Caregiver Assessment(cont.) • Assessing for elder mistreatment • General guideline: ask direct and simple questions • Structure your assessment questions in nonjudgmental and nonthreatening manner • Start with general questions and become progressively more specific if person’s responses indicate elder mistreatment • Interview elder and caregiver together and separately • Not only to detect abusive behavior but assess for caregiver stress • Caregivers may be reluctant to discuss personal problems in front of person who depends on their care

31. Caregiver Assessment(cont.) • Assessing for elder mistreatment (cont.) • Clues to elder abuse include: • Observations that caregiver reluctant to leave elder alone with health providers • Person defers excessively to caregiver to answer questions • Delays between injuries and when treatment is sought • Inconsistencies noted between observed injury and explanation • Lack of appropriate clothing or hygiene • History of “doctor shopping” or not having a primary health care provider

32. Caregiver Assessment(cont.) • Assessing for elder mistreatment(cont.) • Clues to elder abuse include: (cont.) • Positive finding of these clinical situations does not necessarily mean that abuse has occurred, but rather that further assessment is needed

33. Caregiver Assessment(cont.) • Risk factors for abuse • Typical profile of elder abuse victim • Female • 75 years or older • Limited resources • Residing with family • Disruptive behavior • Social isolation • Caregiver financially dependent on elder

34. Caregiver Assessment(cont.) • Theories and frameworks of elder mistreatment • Causes of elder mistreatment are multifaceted • No single theory fully provides an answer • One theory is that elder abuse is caused when caregiver has too many demands on his or her time and acts out by mistreating older adult • Stress should be seen as a trigger for abuse rather than a direct cause • Another theory is cycle of family violence or intergenerational violence

35. Caregiver Assessment(cont.) • Theories and frameworks of elder mistreatment(cont.) • Causes of elder mistreatment are multifaceted (cont.) • Caregivers who are abused as children grow up to abuse the abusive parent • Family members with impairments are more likely to be the primary caretakers because they are the ones at home and available because of a lack of employment

36. Caregiver Assessment(cont.) • Documentation • Proper documentation is important in recording suspected cases of elder mistreatment • Precise recording of findings is crucial because medical records may become part of legal record • If possible, document verbatim descriptions of events and draw or photograph physical findings

37. Environmental Assessment • Environmental modifications can promote mobility and reduce risks • Common environmental risks include: • Lighting • Rugs • Hallways • Cords • Toilet seats • Neighborhood safety • Transportation access

38. Spiritual Assessment • Spiritual assessment is highly individual • May be delayed until provider-client relationship has been developed • Open-ended questions provide a foundation for future dialog • Sample question posed during initial assessment may be “Do you consider yourself to be a spiritual person?” • Involving chaplains or clergy members, when possible and appropriate, can provide older adult with support and can serve as resource to clinician

39. Special Considerations • Cultural considerations • Culture influences all parts of person’s life • He or she may want to try traditional/alternative practices to prevent or treat certain conditions • Learn how person’s culture fits together with suggested interventions • Culture also influences whether older adult relies on: • Family or friends for care and decision making • Disclosure of medical information and diagnosis • Nutrition preferences • End-of-life care, i.e., advance directives and resuscitation preferences

40. Special Considerations(cont.) • Assessing those in pain • Alleviating pain should be priority over other aspects assessment • Providing comfort can help maximize information gathered • It may be necessary to administer premedication • Paramount to remember older adults with cognitive impairment do not experience less pain • This population suffers from conditions typically associated with pain, such as arthritis, osteoporosis, cancer, and shingles

41. Special Considerations(cont.) • Assessing those in pain(cont.) • Alleviating pain should be priority over other aspects assessment (cont.) • A variety of pain assessment scales are available to use in cognitively impaired older adult population • The “gold standard” continues to be person’s self-report

42. Special Considerations(cont.) • Assessing elders with altered cognition • Cognitive impairment may severely restrict ability expression • Gathering information from elder firsthand always best but not always feasible • To ensure collection of reliable information one strategy is to interview caregiver or family • Never assume that he or she cannot respond to questions even with cognitive impairment • Using yes or no questions may prevent frustration • If a family member or caregiver does need to provide collateral information, avoid doing this in front of client

43. Special Considerations(cont.) • Assessment at end of life • Ideally, all aspects of social assessment would be completed before approach to end of life • Maximize interventions to make person comfortable • If interviewing is not possible, pull all available data together to formulate enhancing interventions • Use information from caregivers and other existing sources • Be conscious that caregiver stress may be enhanced during this time of added strain